Preconception Care in the Context of Maternal Mortality Ashlesha K. Dayal, MD Assistant Professor Obstetrics and Gynecology and Women’s Health Albert Einstein

Preconception Care in the Preconception Care in the Context of Maternal Context of Maternal

MortalityMortality

Ashlesha K. Dayal, MDAshlesha K. Dayal, MDAssistant Professor Obstetrics and Gynecology and Assistant Professor Obstetrics and Gynecology and

Women’s HealthWomen’s Health

Albert Einstein College of Medicine/ Montefiore Albert Einstein College of Medicine/ Montefiore Medical CenterMedical Center

Bronx, NYBronx, NY

How to Save a Life

Renal TransplantRenal Transplant29 y/o P0 presents to MFM for 129 y/o P0 presents to MFM for 1stst PNV at 15 wks PNV at 15 wksSLE, renal failure, dialysisSLE, renal failure, dialysis1998 Renal transplant from sister 1998 Renal transplant from sister – Failed after 6 days, secondary to thrombosisFailed after 6 days, secondary to thrombosis

1998 21998 2ndnd renal transplant from husband renal transplant from husband – – stable on immunosuppresive meds for 6 yearsstable on immunosuppresive meds for 6 years

Nephrologist stops meds at 7 wks of pregNephrologist stops meds at 7 wks of pregAbnormal u/a & inc creatinine – 10 wksAbnormal u/a & inc creatinine – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksRenal bx in pregnancy to r/o rejection – 10 wksHemorrhage from bx – nephrectomyHemorrhage from bx – nephrectomy

Renal TransplantRenal Transplant

Pregnancy on dialysis since 10 wksPregnancy on dialysis since 10 wks

Uncontrollable HTN, seizures at 23 wks, pt Uncontrollable HTN, seizures at 23 wks, pt declines TOP despite risk of maternal declines TOP despite risk of maternal deathdeath

Fetus IUGR (280gm at 24 wks) – IUFDFetus IUGR (280gm at 24 wks) – IUFD

Patient anephric on dialysis, awaits Patient anephric on dialysis, awaits transplanttransplant

Renal TransplantRenal Transplant Preconception Counseling & Preconception Counseling &

RecommendationsRecommendations

Evaluate length of time without rejectionEvaluate length of time without rejection

Continue immunosuppressive medicationsContinue immunosuppressive medications– Benefit of controlling rejection outweighs Benefit of controlling rejection outweighs

theoretical risks of medicationstheoretical risks of medications

Obtain baseline renal functionObtain baseline renal function

Folic acidFolic acid

20072007

The State of Maternal The State of Maternal Mortality……..Mortality……..

Daily Death Toll: during pregnancy & in childbirthduring pregnancy & in childbirth

WORLDWIDE

Lifetime risk of Maternal Death Lifetime risk of Maternal Death

Africa Africa 1 in 201 in 20

Asia Asia 1 in 941 in 94

Latin America/Caribbean 1 in 160Latin America/Caribbean 1 in 160

AustraliaAustralia 1 in 831 in 83

Developed Regions Developed Regions 1 in 28001 in 2800

Source: JAMWA 2001

MMR Industrialized Nations, 1990-1994

ACOG/CDC DefinitionsACOG/CDC DefinitionsPregnancy-associated death.Pregnancy-associated death.

The death of a women while The death of a women while pregnant or within one year pregnant or within one year of termination of pregnancy, irrespective of causeof termination of pregnancy, irrespective of cause..

Pregnancy-related death.Pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, irrespective of the duration & site termination of pregnancy, irrespective of the duration & site of the pregnancy, of the pregnancy, from any cause related to or from any cause related to or aggravated by her pregnancy or its managementaggravated by her pregnancy or its management, but not , but not from accidental or incidental causes.from accidental or incidental causes.

Not-pregnancy-related death.Not-pregnancy-related death.The death of a women while pregnant or within one year of The death of a women while pregnant or within one year of termination of pregnancy, due to a cause termination of pregnancy, due to a cause unrelated to unrelated to pregnancypregnancy..

Source: Berg, Atrash, Zane, Barlett. Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta: Center for Disease Control and Prevention 2001.

Maternal Mortality: Maternal Mortality: Nationally Nationally

and in and in New York StateNew York StateHealthy People 2010 Goal:

3.3 Per 100,000 livebirths

Maternal Mortality Ratios Maternal Mortality Ratios 1987 - 19961987 - 1996

9.7

11.7

3.8

11.7

9.1

5.37.5

12.3

7.4

7.7

11.9

3.8

6.44.3

6.3

6.4

9.1

5.3

9.5

4.6

5.95.1

4.3

6.3

3.4

6.9

3.6

4.6

1.9

5.9

3.5

3.7

8.1

3.3

6.1

7.7

6.2 6.2

5.8

6.3

6.7

8.2

10.710.8

7.5 4.56.9

Source: NCHS, Vital statistics

12.03.1

22.8 (D.C.)5.2

> 7.4

5.3 - 7.4< 5.3

National: 7.7 / 100,000 (1987-1996)

Maternal Mortality Ratios for Maternal Mortality Ratios for White Women:1987-1996White Women:1987-1996

5.3

6.2

3.4

6.7

9.2

5.03.6

5.1

5.8

6.3

6.3

3.9

5.2

5.9

6.1

3.9

7.0

3.6

5.64.5

3.2

6.5 5.76.9

3.0

6.7

6.1

4.6 4.1

3.8

4.5

7.0

4.9

5.56.6

4.3 4.03.9


7.62.7

4.0

> 7.45.3 - 7.4< 5.3unable to calculate reliably

Note: The colors on these maps show the states divided into three terciles based on their MMR.

Maternal Mortality Ratios for Maternal Mortality Ratios for Black Women 1987-1996Black Women 1987-1996

24.8

18.9

21.1

22.6

20.5

15.3

17.4

21.2

20.5

27.3 15.9

16.2

17.9

18.4 12.4

12.0

16.8

19.5

20.317.4

21.313.319.0

28.78.7

25.7 (D.C.)

> 7.47.4 - 5.3< 5.3unable to calculate reliably


15.9 in NYS15.9 in NYS

A Regional Look at Maternal A Regional Look at Maternal Mortality Rates* for the Mortality Rates* for the

Year 2000Year 2000

*Per 100,000 livebirths

9.5 in Upstate New York9.5 in Upstate New York

23.1 in NYC23.1 in NYC

Trends in Maternal Mortality Ratio by Race/Ethnicity:NYC OVS, 1993-2002

0

10

20

30

40

50

60

70

80

90

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Pe

r 1

00

,00

0 L

ive

Bir

ths

Black non-Hispanic White non-Hispanic Puerto Rican

Other Hispanic Asian/Pacific Islander

Source: NYC DOHMH Office of Vital Statistics

Comparing Leading Causes of Death Comparing Leading Causes of Death (%)(%)

CauseCauseInternationalInternational

PRMR*PRMR*

National PRMR National PRMR

N=4200**N=4200**

NYC PRMR NYC PRMR

N=119N=119

EmbolismEmbolism NegligibleNegligible 20%20% 7%7%

Hypertensive Hypertensive DisordersDisorders 12%12% 16%16% 10%10%

HemorrhageHemorrhage 25%25% 17%17% 32%32%

Infection/Infection/SepsisSepsis 15%15% 13%13% 7%7%

OtherOtherObstructed Obstructed Labor 8%Labor 8%

Unsafe Ab 13%Unsafe Ab 13%

Cardiomyopathy Cardiomyopathy 8%8%

CVA 5.0%CVA 5.0%

Anesthesia 2%Anesthesia 2%

CardiomyopatCardiomyopathy 8%hy 8%

Anesthesia 7%Anesthesia 7%

*International WHO 1993, JAMWA 2002

**National MMWR 2003

***NYC BMIRH 1998-2000

Preconception BackgroundPreconception Background

In 2000, 4.1 million women aged 18-44 In 2000, 4.1 million women aged 18-44 made visits to family physiciansmade visits to family physicians

Opportune times for preconception Opportune times for preconception discussions—well woman visit, discussions—well woman visit, negative pregnancy test, follow up negative pregnancy test, follow up visits after spontaneous or voluntary visits after spontaneous or voluntary abortionsabortions

Preconception CarePreconception Care

What is preconception care?What is preconception care?– Risk assessment for a future pregnancyRisk assessment for a future pregnancy– Assessment of broad range of risk factorsAssessment of broad range of risk factors– Timing of this risk assessmentTiming of this risk assessment


Identifies reducible or reversible risksIdentifies reducible or reversible risks

Maximizes maternal healthMaximizes maternal health

Intervenes to achieve optimal Intervenes to achieve optimal outcomesoutcomes

From March of Dimes Preconception Curriculum


Reframes IssuesReframes Issues

Adds an anticipatory elementAdds an anticipatory element

Focuses on the impact of pregnancyFocuses on the impact of pregnancy

From March of DimesPreconception Curriculum

Elements of Preconception CareElements of Preconception Care

Focuses on elements which must be Focuses on elements which must be accomplished prior to conception or accomplished prior to conception or weeks thereafter to be effectiveweeks thereafter to be effective– Risk assessmentRisk assessment– Health promotionHealth promotion– Medical and psychosocial interventionsMedical and psychosocial interventions

From March of DimesPreconception Curriculum

Components to Preconception Components to Preconception CareCare

Medical HistoryMedical History

Pychosocial IssuesPychosocial Issues

Physical ExamPhysical Exam

Laboratory testsLaboratory tests

Family HistoryFamily History

Nutritional AssessmentNutritional Assessment


Medical historyMedical history– Particular medical conditions that lend Particular medical conditions that lend

themselves to Pre-pregnancy managementthemselves to Pre-pregnancy managementDiabetesDiabetes

HypertensionHypertension

Seizure disorderSeizure disorder

Cardiac diseasesCardiac diseases

Lupus, sickle cell disease, renal diseaseLupus, sickle cell disease, renal disease


Obstetrical HistoryObstetrical History– Risk factor assessment for Preterm Risk factor assessment for Preterm

DeliveryDeliveryPrevious preterm delivery—most important risk Previous preterm delivery—most important risk factorfactor

History of fetal loss—what gestational age?History of fetal loss—what gestational age?

Interpregnancy interval--<18 monthsInterpregnancy interval--<18 months

Obstetrical conditions at high risk---Obstetrical conditions at high risk---incompetent cervix, history of premature incompetent cervix, history of premature rupture of membranes, uterine malformationsrupture of membranes, uterine malformations


Pychosocial IssuesPychosocial Issues– Screening for Depression—discussion of Screening for Depression—discussion of

medication, therapy and PP depression risk medication, therapy and PP depression risk – Emotional or Physical Abuse--offer confidential, Emotional or Physical Abuse--offer confidential,

safe screening and discussion safe screening and discussion Assess safetyAssess safety

One third of women reporting violence report escalation One third of women reporting violence report escalation in pregnancyin pregnancy

Role of health care providerRole of health care provider

Components to preconception Components to preconception carecare

Immunization HistoryImmunization History– Rubella, VaricellaRubella, Varicella

Physical examPhysical exam

Laboratory testsLaboratory tests– In patients with particular histories, In patients with particular histories,

antiphospholipid screens best done prior antiphospholipid screens best done prior to pregnancyto pregnancy


Family HistoryFamily History– Genetic historyGenetic history– Discussion of age-related risksDiscussion of age-related risks– Discussion of disease related risksDiscussion of disease related risks– Carrier screeningCarrier screening– Potential for egg or sperm donation or Potential for egg or sperm donation or

early genetic screeningearly genetic screening


Nutritional AssessmentNutritional Assessment– Folic Acid for Everyone!! Modifies risk for neural Folic Acid for Everyone!! Modifies risk for neural

tube defect—0.4 mg everydaytube defect—0.4 mg everyday– BMI Assessment: underweight, overweightBMI Assessment: underweight, overweight– Identifiying particular nutritional targets: iron Identifiying particular nutritional targets: iron

deficiency, vitamin excess (A and D)deficiency, vitamin excess (A and D)– Pica screeningPica screening

Lifestyle Risk AssessmentLifestyle Risk Assessment

Effects of various substance use on Effects of various substance use on pregnancy and fetuspregnancy and fetus

Screening for use and abuseScreening for use and abuse

Referral for treatment Referral for treatment options/programsoptions/programs

Emphasize using pregnancy as Emphasize using pregnancy as motivation for changemotivation for change

Tobacco and PreconceptionTobacco and Preconception

Tobacco: most preventable cause of Tobacco: most preventable cause of LBWLBW– Associations with abruption, placenta Associations with abruption, placenta

previa, preterm deliveryprevia, preterm delivery– Cessation at any time in pregnancy Cessation at any time in pregnancy

improves risksimproves risks– How to offer help with cessationHow to offer help with cessation

Alcohol and PreconceptionAlcohol and Preconception

Most preventable cause of Mental Most preventable cause of Mental Retardation---fetal alcohol syndromeRetardation---fetal alcohol syndromeMost common teratogen exposureMost common teratogen exposureDose related effects---worst outcomes Dose related effects---worst outcomes with “binge drinking”with “binge drinking”Effects can be seen at all stages of Effects can be seen at all stages of pregnancypregnancy

Drug use and PreconceptionDrug use and Preconception

Cocaine Cocaine

Heroin Heroin

Methadone Methadone

Congenital anomalies, Congenital anomalies, placental abruption, LBWplacental abruption, LBW

Newborn withdrawl, LBWNewborn withdrawl, LBW

Newborn withdrawlNewborn withdrawl

““The failure to address preventable The failure to address preventable maternal disability and death represents maternal disability and death represents one of the greatest social injustices of our one of the greatest social injustices of our times….Women’s reproductive health risks times….Women’s reproductive health risks are are notnot mere misfortunes and unavoidable mere misfortunes and unavoidable disadvantages of pregnancy, but rather, disadvantages of pregnancy, but rather, injustices that societies are able and injustices that societies are able and obliged to remedy…”obliged to remedy…”

Rebecca J. Cook, Bernard M. Dickens, WHO, 2001

Maternal Mortality Ratios per 100,000 Live Births, 2000WHO, United Nations

Documents

Preconception Care in the Context of Maternal Mortality Ashlesha K. Dayal, MD Assistant Professor Obstetrics and Gynecology and Women’s Health Albert Einstein